Background: The Palo Alto VA Hospital has an interdisciplinary Clinical Command Center (C3) that includes “Flow” nurse practitioners (NPs) who work closely with case management, social work and primary medical teams to identify and address barriers to care and assist in discharge planning and coordination. We have created a novel collaboration between a C3 Flow NP and inpatient geriatrics in providing a 4Ms (What Matters Most, Medication, Mentation, Mobility) assessment for high-risk older to assist in complex case management.
Purpose: The purpose of our intervention is to integrate principles of age friendly care into the case management workflow for older hospitalized veterans via a collaboration between the C3 and inpatient geriatrics. Our goal is to utilize the information gathered from the 4Ms assessment to identify patient’s needs and to allow patients an opportunity to tell us in their own words “What Matters Most” to them in terms of their hospitalization. In particular, we aim to connect patients with the right community services and medical referrals at the right time and to provide care consistent with the patient’s goals for hospitalization.
Description: During daily C3 rounds, the Flow NP and inpatient geriatrician identify high-risk hospitalized older adults age 65 and over based on their admission diagnosis. The patients are then screened for appropriateness for 4Ms assessment, with prioritization of patients with unclear discharge plans. There is an emphasis on the “What Matters Most” and “Mobility” assessments to identify patient goals, clarify the nature and trajectory of functional decline, and identify need for additional services or referrals. Between March and November 2022, 212 older adult patients (age 65-99) were identified with high-risk admission diagnoses including falls (n=30), failure to thrive (n=28) placement (n=25), and “found down” after a fall (n=6). 30 assessments were completed of the highest risk individuals. Outcomes of the assessments included referrals to audiology, optometry, podiatry, and outpatient cognitive assessment, as well assistance with meals, transportation and caregiver support.
Conclusions: “Geriatricizing case management” via a 4Ms assessments is feasible and can be completed in the inpatient setting in a way that is relevant and integrated into the care of patients. For patients with prolonged or repeat hospitalizations where care team members rotate frequently, our model of care can help provide continuity and navigate complex care coordination. In particular, identifying specific patient needs and connecting them to the right services and referrals at the right time can aid in facilitating the transition to the next level of care. Lastly, eliciting “What Matters Most” from our frail, older patients allows the interdisciplinary team to better align with patients’ stated goals.